347001241-12-27-2023-27-AS-KGOD-CYWQ3B-20231227104828

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347001241
Report Date: 10/31/2023
Date Signed: 12/27/2023 10:49:01 AM

Document Has Been Signed on 12/27/2023 10:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	ESKATON GOLD RIVER LODGE		FACILITY NUMBER:	347001241
ADMINISTRATOR:	NEAL TORRES		FACILITY TYPE:	740
ADDRESS:	11390 COLOMA RD		TELEPHONE:	(916) 852-7900
CITY:	GOLD RIVER	STATE: CA	ZIP CODE:	95670
CAPACITY:	134	CENSUS: 84	DATE:	10/31/2023
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Neal Torres		TIME COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 10/31/23 at 1:00pm, Department representatives Kevin Gould (LPA), Kim Viarella (LPA), Czarrina Camilon-Lee (LPM), Stephen Richardson (LPM) and Stephenie Doub (RM) met with representatives from Eskaton Gold River Lodge to discuss recent compliance issues at the facility and the steps the facility is taking to address the department's concerns. Representing Eskaton Gold River Lodge is Sheri Peifer - President & CEO, Neal Torres - Administrator, Tighe Hammam - Senior VP of Operations, Jennifer Marlette - Executive director of Quality and Compliance, Tina Riley - Quality and Compliance Nurse, Tom Garberson - General Counsel, Scott Winans - SVP Resident Services and Joel Goldman - Outside Counsel. Department and facility representatives discussed medication administration errors documented in complaint and case management inspections. Department and facility discussed the proposed changes made by the facility including changes to acceptance of diabetic residents who cannot manage their own blood glucose testing and insulin administration. Department addressed concerns with staffing and potential staffing changes to ensure staff are not overworked and overtired that could potentially result in medication administration errors. Separate MAR for Insulin dependent residents. Distinguish between long acting and short acting insulin to assist residents and reduce errors. Department and facility representatives discussed re-evaluation of residents with a change in condition including residents who may express suicidal ideation. Facility provided statements regarding the training and interventions in place for residents who may have a change in condition or make statements or actions of self harm. Department provided feedback including calling 911 when or if a resident presents a danger to themselves. Facility has a plan in place for 1 to 1 staff for any resident who makes statements of self harm or suicidal ideation. Report continued on LIC 9099-C.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ESKATON GOLD RIVER LODGE	FACILITY NUMBER: 347001241
	VISIT DATE: 10/31/2023

NARRATIVE

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Department and facility discussed facility training for staff members ensuring they are empowered and aware of when they are required to call 911 to ensure timely medical care for residents in care. the facility presented steps the facility has taken to address training and supporting staff members to be empowered and call 911 when there is an emergency.

Department and Facility discussed facility changes to ensure the health and safety of residents in memory care from reported incident where a resident was targeted by another resident and physically assaulted. Facility representatives discussed the steps the facility has taken to address the health and safety to ensure there are additional visuals on all residents in areas that may be outside the view of most common areas. Ensure staff make appropriate rounds and ensure all residents are accounted for and supervised. Facility steps for enhanced supervision and safety include additional staffing at front desk and changes to facility accessibility. Department and facility discussed education of residents to facility access changes and "campus safety".

Facility and Department discussed the evaluation and retraining of Med Tech and Nurses including monthly competency checks. Consultants make routine audits and inspections at the facility to ensure compliance with title 22 regulations. Quality and compliance nurses have been activated to review medication administration and ensure retraining at a minimum of once per month. Revision of admission agreement for potential insulin administration residents.

Facility agreed to provide department written policies and procedures for re-valuation or residents, a detailed description of new Eskaton training academy and a description of policies and implementation for Care Coordination Meetings.

Report continued on LIC 9099-C2

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ESKATON GOLD RIVER LODGE	FACILITY NUMBER: 347001241
	VISIT DATE: 10/31/2023

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In summary the facility agreed to the following and will provide the department of documentation of policy and procedure changes.

Attracted new staff to oversee positions such as resident care coordinator and wellness nurse. Eskaton central support and senior RCFE quality and compliance nurse supplied facility with enhanced support including audits, record review, training and competency checks.
Retraining of all nurses and med tech on medication passing techniques, policies and systems. Updated training on insulin administration, diabetes management. Quality and competency checks for all nurses in focused areas.
Service changes: facility has ceased accepting new residents who cannot manage their own blood glucose monitoring and insulin administration. Current residents on diabetes management program will continue but the program will be discontinued once all residents in placement move out.
Front desk coverage and facility locks: front desk is now staffed until 10pm seven days a week. Front door lock has been replaced with keyed system to ensure only authorized staff can lock and unlock doors.
Implementation of Care Coordination Meetings (CCMs) with an emphasis on reviews of residents with an emphasis on those residents who have experienced recent changes in condition or care needs. These meetings are intended to be proactive and preventative, identifying opportunities to meet residents’ changing needs or emerging issues and ensuring that all departments are aware of those needs.
New Training Academy: Eskaton opened the centralized Eskaton Academy in June 2023. The Academy is required for all new direct care staff, and many existing staff have also completed it. The program is five days of intensive training that meets the requirements for RCFE caregivers.
Integration of new EMAR system with estimated roll out early 2024.
The Great Catch pilot is now fully developed. It will be implemented on November 1 with an initial pilot at one community in the Bay Area. We plan to refine and expand it based on learnings from the pilot, and roll it out organization-wide in Q1 of 2024.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's meeting. An exit interview was conducted, and a copy of this report was mailed to the facility for signature.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

LIC809 (FAS) - (06/04)

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